Indian J Pediatr 1991; 58 : 341-344 i

Control of Tetanus Neonatorum in a Rural Area S.IC Kapoor, V.P. Reddaiah and J. Lobo

Centre for Community Medicine, All h~dia 7nstitute of Medical Sciences, New Delhi.

Experience in the control of tetanus neonatorum (TN) in a rural area is presented. TN was reduced by training of dais, increasing the coverage of tetanus toxoid to pregnant women and distribution of presterilized delivery kits to pregnant ladies for use by birth attendants. The problems of untrained birth attendants, effectiveness of tetanus toxoid coverage and place of delivery are discussed.

Key Words : Tetanus neonatorum; Neonatal mortafity; Birth dants; Delivery kits; Tetanus toxoid.

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plementary strategies (i) Hygienic practices during and after delivery (ii) Immunization against tetanus. India has adopted training of birth attendants, at least one per each village, and coverage of 100% TT to pregnant women. This article describes our experience in a rural project in elimination of TN.

Though tetanus neonatorum (TN) is preventable and a potent vaccine i.e. tetanus toxoid (TT) is available, it is a pity that an estimated 7,50,000 neonates die in the world due to tetanus neonaturum? About 30% of this is in our country, especially in rural areas. 2 TN is considered a problem in any part if tetanus neonatorum mortality rate (TNMR) is more than 2/1000 live births. Realising the importance of this, WHO included T.T. to pregnant ladies in EPI and was continued in UIP, after 1985, with a target to achieve 100% coverage of Antenatal mothers with T.T. by 1990. As per the latest indication, a coverage of 65% is reported) The VIII International conference on tetanus in 1987 passed a mile stone resolution calling for elimination of TN. This can be done by two corn-

MATERIAL AND METHODS TN death is defined as a baby born to a woman, (not immunized with TT) who develops the illness after 48 hours with inability to suck followed by history of stiffness and/or convulsions, death occurring within first four weeks. This definition has been used after 1976. Before this there was a confusion in differentiating septicemia and TN and probably both were included in TN. The Comprehensive Rural Health Services Project at Ballabgarh is the rural field

Reprint requests : Dr. V.P. Reddaiah, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi. 341

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THE INDIANJOURNAl. OF PEDIATRICS

practice area of Centre for community medicine of All India Institute of Medical Sciences, New Delhi. It has an area covering 28 villages, which are grouped to be served by sub-centrcs each catering to a population o( 6 to 8 thousand. These are part of primary centre settings. The workers make systcmatic home visits so that each house in the arca is visited twice a month. A complete demographic record of each family is maintained, all births and deaths are recorded on regular visits by the workers. It is complemented by a census every ycar. Deaths arc verified by the" male supervisor within a fortnight of reporting and 10% of the deaths arc verified by the doctor. This results in almost 100% coverage of births and deaths. The female worker is responsible, among her other duties, for the registration of all antenatal cases, distribution of iron and folic acid tablets, immunization with tetanus toxoid as per the schedule of the EPI/UIP, health cducation and to conduct deliverics. As the female worker is visiting each household regularly every month, she is able to detect a pregnancy early. She is responsible for providing early immunization with tetanus toxoid which is one of the most important strategies of preventing

Vol. 58, No. 3 tetanus neonatorum. Tetanus immunization to pregnant women was initiated in 1970. The second strategy adopted in this area after 1982 was to distribute to every registered pregnant woman a sterilized delivery kit containing gauze pieces, half a razor blade and thread. This kit is given towards the end of the pregnancy and the woman is advised that anyone who c o n ducts the delivery, should use the kit for cutting and tying the cord and to insist that the birth attendant washes her hands with soap before handling the delivery. Some local dais have been trained and periodic inservice training of the trained birth attendants cmployed with us is also carried out by the doctors at the PHCs. RESULTS The distribution of dcliveries conducted at home or hospital and the coverage of pregnant ladies with TT and neonatal mortality rates (NNMR) and tetanus neonatorum mortality rates (TNMR) are presented and discussed. As seen from the Table 1, 90% of deliveries were conducted at home and about 70% by untrained persons. There was an increase in deliveries conducted by the PHC staff over 15 year period from 4.2% in 1972 to 12.1% in 1987. Hospital

TAaL~1. Deliveries Conducted by Place and Birth Attendant Year

Number of live births

Hospital Delivery

PHC Staff

Home delivery conducted by Trained Dais

Untrained persons

1972

1844

30 (1.6%)

77 (4.2%)

398 (21.6)

1339 (72.6)

1977

1834

156 (8.5%)

130 (7.1%)

210 (11.5)

1338 (73.0)

1982

1958

192 (9.8%)

176 (9.0%)

540 (27.6)

1050 (53.6)

1987

1951

37 (1.9%)

237(12.1%)

253 (13.0)

1524 (73.0)

REDDAIAII HI"AL: CONTROLOF TETANUS NEONATORUM

343

T~Lv. 2. Tetanus Toxoid Coverage, NNMR and TNMR Year

TT coverage of pregnant women

NNMR/1000 live births

TNMR/1000 live births

1972

38.8%

42.3

14.6

1977

31.6%

39.2

4.9

1982

70.0%

22.9

1.02.

1987

93.0%

17.9

0.0

deliveries never exceeded 10%. The deliveries conducted by trained dais fluctuated between 910-30%. It will be observed from the Table 2. that there was a sudden increase in the coverage of tetanus toxoid to pregnant ladies from 1982 and reached a level of 93.0% by 1987. There was a gradual and sustained reduction in NNMR from 42.3/1000 live births in 1972 to 17.9/1000 in 1987 but what is important to note is the disappearance of TN deaths from 14.6/1000 live births in 1972 to nil by 1987. DISCUSSION As is evident from the results provided, there is no way that we can reduce the domiciliary deliveries or deliveries conducted by untrained people in the foreseable future. Though training of birth attendants is necessary, it is just not possible to train all birth attendants as many deliveries are conducted by household members or neighbours or relatives. Though training traditional birth attendants is a step in the right direction, it alone cannot solve the problefla 9as is evident in this study. India has trained more than 5 lakh dais with atleast one for each village but only 33% (1983-88) of births were attended by trained atten-

dants? Realising this, the project emphasised on the antenatal care and education regarding hygienic delivery. Though there was no EPI programme before 1978, realising the importance of TN in the area, the project embarked upon T r to pregnant ladies but as can be observed the coverage was < 40% until 1977 because there was resistance to injections during pregnancy and also due to lack of concerted efforts. But there was a reduction in TNMR not in NNMR. Before 1976 the deaths due to TN was actually a composite of deaths of TN and septicemia being lumped together due to lack of guidelines for discrimination between the two. It was further observed that rarely cases of TN were being seen at h0spital. Guidelines were provided to brand the death to septicemia or TN separately. This is the reason for the reduction observed in TNMR though NNMR has not come down to any significant level by 1977. Introduction of EPI strategy in 1978 and the impetus given to Antenatal care during international year of child in 1979, greater efforts were made to identify pregnant women at early stage for providing antenatal c,3.re which included tetanus toxoid immunization, iron and folic acid supplements, recognition and referral of high risk pregnancies resulted in significant reduc-

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THE INDIAN JOURNAL OF PEDIATRICS

tion of T N M R (<2/1000 live births) by 1982 though not elimination but the NNMR fell drastically. Efficacy of I q ~ two doses was stated to be 74-95%. 5,7A study in Bangladesh has shown a very good reduction in NNMR and TNMR by training birth attendants and "IT two doses during pregnancy. 8 Further reduction in NNMR and elimination of TN could be achieved by 1987 by further increase in coverage of antenatal care which included Tetanus toxoid (93%) and introduction of sterilized delivery kits in 1982 with advice regarding insisting on handwashing of birth attendants. Current level of TT coverage which is a part of Antenatal care in the country is only 65%. 3 As can be seen from the study, unless the immunization status is raised to atleast 85%, though 100% is desirable as targeted under EPI, the mortality due to TN cannot be reduced. This should be accompanied by nation wide distribution of safe delivery kits to all pregnant women with instruction for use. It is not possible to achieve the targets of bringing down IMR to below 60/1000 live births by 2000 A.D. in the country without both strategies put into use on a large scale. Based on these findings, we recommend (i) increasing the coverage of antenatal care including qq" to pregnant ladies (if) distribution of simple presterilized delivery

kits to pregnant ladies in the last month and (iii) instructions for its use. i~rE~NCES

1. Robert Steinglass. The control of neonatal tetanus. Mothers and Children 1989; 9 : 4-5. 2. UNICEF. An Analysis of the Situation of Children bz bldia. UNICEF Regional Office for South East Asia, New Delhi 1984; pp 36. 3. Ministry of Health ~ d Family Welfare, Government of India. Annual Report 1989-90. pp 22. 4. James P Grant. The State of the Worlds Children 1990. UNICEF, pp 88. 5. Arnold RB, Soewarso TI, Karyado A. Mortality from neonatal tetanus in Indonesia. Results of two surveys. Bull WHO 1986; 64 : 259-262. 6. Dhillon H, Menon PC. Active immunization of women in pregnancy with two injections of adsorbed tetanus toxoid for prevention of tetanus neonatorum in Punjab. Indian J Med Res 1975; 63 : 583589. 7. Henderson RH, Keya J, Haden G e t al. I~trnunizing the children of the world. Progress and perspectives. Bull WHO 1988; 66 : 5.~15-543. 8. Rahman S. The effect of traditional birth attendants and tetanus toxoid in reduction of neonatal mortality. J Trop Pediatr 1982; 28 : 163-165.